Saturday, February 20, 2010

Prevention vs. Treatment

The global recession was a horrific experience for many people across the planet. The realization that spending beyond your means is a dangerous game with dire consequences was a harsh return to reality for many people throughout the developed world.

Now, more than ever, if I suggested that your current spending was putting you deeper and deeper into a debt that you would have to spend the rest of your life repaying, you would probably rush to your financial planner and reorganize your budget.

So why are obesity rates across the developed world increasing? Why are we so comfortable with the idea of eating ourselves to death?

If most would agree that it is better to stay out of debt than to spend a lifetime repaying debt, why do we not see that overeating is analagous to going into debt and that that chronic illness like diabetes and ischemic heart disease from atherosclerosis is analagous to spending a lifetime repaying that debt?

It is because when it comes to their health, most people lack foresight. Many feel that they can just take medication when they are sick. They don't care to exercise and eat healthy so that they won't need the medication in the first place.

In many ways I understand this thought process. I might even support this behaviour if we actually had pills that would cure disease with no costly or chronic side effects. Unfortunately, that is not the scenario that is available to us. Metformin and glyburide do treat diabetes, but they are not a cure. Diabetics are still chronically ill and face a decreased quality of life despite the availability of diabetic medication, which they will have to take for the rest of their lives. As for atherosclerosis, once your arteries are clogged with fat, your heart will not function to its full potential...ever, regardless of how much nitro you take.

Ignoring prevention in favour of therapy is not solely the fault of patients (it is still mostly their fault; after all, you should take responsibility for your own body and health!). Physicians tend to focus on treatment; they spend significantly more time with the already sick patient than they do with the healthy patient who will be sick in the future if nothing is done now.

I attribute this phyician focus on treatment partially to physician training and mostly to the health care system. Medical school focuses on teaching us how to heal the sick much more than it focusses on how to prevent the healthy from becoming sick. This may be unavoidable because you absolutely need to ensure that your doctors know how to heal the sick and there are so many diseases out there it already takes at least 6 years of training to become competent enough to practice medicine. Does that mean we need another set of health care professionals working on prevention? Or maybe we should have a new specialty physician who focusses on prevention?

The health care system has a role to play in physician interaction with patients because MSP, the government organization that pays physicians for their services, does not provide much financial compensation for preventative treatment. I don't want to get into an argument about how much doctors should/should not care about finances when they are the ones entrusted to care for the sick, but realize that human nature will motivate anyone to act in a manner that maximizes their profit to effort ratio. If we want to see doctors spending more time on prevention with patients, maybe the health care system should value prevention more.

In the end though, as I have already said, you can't blame your doctor or your health care system for making you fat if you are the one eating poorly when you know better... and in this country, most people do know better.

Thursday, February 11, 2010

Looking for a kidney? Check the pelvis

I was working with a family doctor who asked me to go in and do a cardiac and abdomenal physical exam on a patient who had "interesting findings". He told me to make sure I palpated the kidneys. I was also told that the history had already been taken so I didn't have to bother with that.

I began with a cardiac exam. The only significant finding was a grade 2/6 (very quiet) systolic murmur. I figured the doctor asked me to do a cardiac exam on this patient because he wanted me to find that murmur, so I was happy to find it so quickly. I then continued with the rest of the exam.

I began the abdomenal exam thinking this patient must have a kidney tumour or some kind of kidney inflammation because the doctor made a point of asking me to palpate the kidneys. Normally you cannot feel a kidney on an abdomenal exam because they are surrounded by fat and muscle. The only time you can feel a kidney is when it is pathologically enlarged, or so I thought...

I was trying to palpate the kidneys for five minutes but I couldn't feel anything. Not being able to palpate enlarged kidneys may be expected in a fatter patient, but this patient was relatively thin. Finally, the patient, clearly seeing that I was struggling, began laughing at me. He decided to put me out of my misery and pulled his shorts down past his groin revealing an abnormal bump in his pelvic region...his kidney.

Turns out this patient had bilateral pyelonephritis that ended up destroying his kidneys, so he had to have a transplant. Often with kidney transplants the old kidneys are not removed; instead, their ureters (tubes connecting them to the bladder) are cut and ligated to the new, transplanted kidney, which is placed in an empty space in the pelvis.

Tuesday, February 9, 2010

Open Sourcing Research Software

An article in the Guardian calls for researchers to open source (release to the public) the computer code they use in their research.

As a former programmer, I think that this is a great idea. It is surprisingly easy for even the most talented programmer to make simple mistakes in their code that cause their program to provide erroneous, misleading results. Asking for the computer code to be released to the public will allow skeptics and peer reviewers the chance to criticize how data was analyzed. This criticism can catch mistakes and lead to more powerful experiments, but will researchers have too much ego to release their code?

In industry, programming errors are caught by demanding that programmers test their own code and then having a team of testers test the code. Unfortunately, the luxury of a robust testing team is not afforded to many researchers. Also, it is hard to expect, for example, a biology researcher, who is a self taught programmer, to create a detailed and powerful test harness for his software.

I would actually be surprised to see the open sourcing of research code become a common practice because I think many inexperienced programmers who program for research will be too embarrassed to release their code in a domain where professional software developers are able to criticize their work. I blame this on the programming profession rather than the researchers. Programmers are notorious for being outspoken and rude when commenting on amateur code. Another barrier to this practice is that code that is being released to the public domain needs to be readable/understandable, instead of being readable to only the programmer who wrote the code. This preparation will add time to the already busy schedules of most researchers.

Unfortunately, I suspect this will be one of those great ideas that many support, but few practice.

Thursday, February 4, 2010

Lithium perscriptions are not supplements

No, I cannot give you a prescription for lithium.


Because lithium is used to treat bipolar disorder and you do not have bipolar disorder. I understand that your naturopath tested your hair for trace elements and his tests show that you have low levels of lithium; however, you just said you didn't have any health complaints.

You want to try 5 mg of lithium per day, but the smallest tablets I can find are 100 mg. Are you really going to cut this tablet into 20 pieces? Even if you did, if anything happens to you, like thyrotoxicosis leading to hypothyroidism (a side effect of lithium)... how am I going to explain that I gave a perfectly healthy patient, who was not bipolar, a prescription for lithium?